If the PSA level shows that the prostate cancer has not been cured or has come back (recurred) after an initial attempt to cure it, further treatment may be an option. Follow-up therapy will depend on where the cancer is thought to be located and what treatment(s) you have already had. Usually, the same type of treatment is not an option because of the increased potential for serious side effects. For example, men who have already had radiation therapy to the prostate cannot have that area treated with radiation again. Imaging tests such as CT, MRI, or bone scans may be done to get a better idea about where the cancer may be.
If the cancer is still thought to be localized to the area of the prostate, a second attempt at curative treatment may be possible. If you've had a radical prostatectomy, radiation therapy may be an option. If your first treatment was radiation, treatment options include cryosurgery or radical prostatectomy, but when radical prostatectomy is done after radiation, it does carry a higher risk for potential side effects including incontinence.
If the cancer has spread outside the prostate gland, it will most likely go first to nearby lymph nodes, and then to the bones. Much less often the cancer will spread to the liver or other organs.
When prostate cancer has spread to other parts of the body (including the bones), hormone therapy is probably the most effective treatment, but it is very unlikely to cure the cancer. Usually the first treatment is an LHRH analog. If this stops working, an anti-androgen may be added. Other hormonal agents such as ketoconazole or estrogens (female hormones) may be helpful and can sometimes slow or stop the cancer from growing. Hormone therapy will be given as long as the cancer is responding (based on the PSA level and whether or not symptoms develop).
Remember that prostate cancer is usually slow growing, so even if it does come back, it may not cause problems for many years. In a Johns Hopkins University study of men whose PSA level began to rise after surgery for low-grade prostate cancer, there was an average of about 8 years before there were signs the cancer had spread to distant parts of the body. Of course, these signs appeared earlier in some men and later in others.
Hormone-refractory prostate cancer (HRPC)
Cancer that no longer responds to hormone therapy such as LHRH analogs or anti-androgens is considered hormone-refractory, and can be hard to treat. At one time it was thought that chemotherapy was not effective against prostate cancer, but in recent years this notion has been challenged. Several chemotherapy drugs have been shown to reduce PSA levels and improve quality of life. Studies have shown that the drug docetaxel (Taxotere) can improve help men with HRPC live longer, as well as reduce their cancer pain. If docetaxel stops working, the new drug cabazitaxel (Jevtana) can also help. The cancer vaccine sipuleucel-T (Provenge) may also help prolong life for men with HRPC.
Bisphosphonates appear to be helpful for many men whose cancer has spread to the bones. These drugs can reduce pain and even slow cancer growth in many cases. There are also other medicines and methods to keep pain and other symptoms under control. External radiation therapy can help treat bone pain if it is only in a few spots. Radioactive strontium or samarium may reduce pain if it is more widespread, and may also slow the growth of the cancer.
If you are having pain from your prostate cancer, make sure your doctor and entire care team is aware of this. There are many very effective drugs that can relieve pain. But for this to happen, you must make it clear to your doctor that you have pain. For more information, see our document, Advanced Cancer.
There are several promising new agents now being tested against prostate cancer, including vaccines, monoclonal antibodies, and differentiating agents. Because our ability to treat hormone-refractory prostate cancer is still not good enough, men are encouraged to explore new options by taking part in clinical trials.
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